Provider Demographics
NPI:1639322746
Name:EDWARD L RICK DDS MS PC
Entity type:Organization
Organization Name:EDWARD L RICK DDS MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-625-2112
Mailing Address - Street 1:1808 FIRST AVE
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1202
Mailing Address - Country:US
Mailing Address - Phone:815-625-2112
Mailing Address - Fax:815-625-2143
Practice Address - Street 1:1808 FIRST AVE
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-1202
Practice Address - Country:US
Practice Address - Phone:815-625-2112
Practice Address - Fax:815-625-2143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021-0008851223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003466/101354Medicaid